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Tuesday, March 06, 2012

A Photon in the Darkness: Autism and Insurance

I have been very negligent in posting lately, so I plan on setting quite a few posts up in the queue in order to pass along some information to you all. This particular post from "Prometheus" at the A Photon in the Darkness blog seems rather appropriate, even though the date of the post is a bit out of date.

December 22nd, 2011

Earlier this week, I had arranged to have coffee with a close
friend of mine. When I arrived, she was holding a copy of the weekend
edition of the Wall Street Journal and was quite upset about an
article on the “Affordable Care Act” (”Obama-care”). In this article,
it was mentioned that the department of Health and Human Services was
planning to leave it up to the various states whether or not to mandate
“autism treatment” coverage. This, she felt, was a cruel blow to
families with autistic children. Fortunately, I had been through this
all before, many years ago, when my child was first diagnosed with
autism, so I had some perspective to offer.
Back in those dark days, we were casting about for something, anything
to do to help our child, even to the point of attending a “DAN!
conference”. In that “conference” (it was more like a revival meeting
than a conference), we heard repeated, over and over, that health
insurance plans would not pay for anything related to autism, the
dreaded “299.0″ (ICD-9 code for autism). As I later recalled, this
“fact” was most often mentioned by practitioners who offered
“alternative” treatments for autism.
Shortly after returning from that “conference”, I had the opportunity
to question (”interrogate” might describe the flavour of that exchange
better) our paediatrician about that point. He was - and is - an
exceptionally patient person and managed to answer my question without adressing my obvious hostility.
As he explained it, the insurance companies look over each bill and
ensure that - among other things - that the procedural code (CPT codes)
matches up with the diagnostic code. They want to ensure that a doctor
isn’t claiming reimbursement for an appendectomy when the diagnosis is
“bunion”, for example. For this reason, chelation and HBOT aren’t
“approved” for autism because - as I’ve outlined in several ‘blog
postings - they haven’t been shown to be effective in the treatment of
autism, just as appendectomy hasn’t been shown to be an effective
treatment for bunions.
Other issues that arise, especially in the “alternative” treatment of
autism, are when the “treatment” is either of questionable
effectiveness, such as “Applied Behavioral Analysis”, or its
effectiveness has not been demonstrated. Insurance companies usually see
these as “experimental” treatments and refuse to pay for them.
However, parents have also complained that they are unable to get
insurance companies to pay for “mainstream” therapies, such as speech
therapy and psychiatric consultation when the diagnosis was “autism”.
This, according to our patient paediatrician, is due to the ignorance of
the practitioner. There is no universal treatment for “autism” - it is
too broad and heterogenous a diagnosis for that. So, to justify - for
example - speech therapy, another diagnosis is needed, since
the diagnosis of “autism” does not, in itself, imply a need for (or
benefit from) speech therapy. Experienced and well-trained practitioners
are aware of this requirement and so don’t submit bills that don’t have proper justification for the prescribed (or recommended) therapies.
When I later questioned some of the parents who had complained about
having insurance companies refuse to pay for “autism”-related
treatments, I found that a few things kept cropping up: